Evidence-based circumcision policy for Australia

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using “circumcision” with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

• During infancy, circumcised infants are less likely than uncircumcised infants to experience urinary tract infections (UTIs); an estimated 7% of infant males presenting with fever in outpatient clinics and emergency rooms had UTIs, including 20% of uncircumcised febrile infants and 2% of circumcised febrile infants aged younger than 3 months of age. • An estimated 32% of uncircumcised males compared with 9% of circumcised males will experience a UTI in their lifetime, suggesting that circumcision is associated with a 23% absolute decreased lifetime risk of UTI.
• Although most UTIs are treatable, serious complications may occur when UTIs are not diagnosed, recurrent, difficult to treat, or left untreated. Such complications may include sepsis, pyelonephritis, and renal scarring and have been associated with an increased risk for long-term consequences, including hypertension, build-up of kidney waste products (uremia), and end-stage renal disease.
• An estimated 14% of uncircumcised boys compared with 6% of circumcised boys experienced balanitis, irritation, adhesions, phimosis or paraphimosis, suggesting that circumcision is associated with an 8% absolute decreased risk of these conditions. • During adulthood, circumcised males were less likely than uncircumcised males to experience penile cancer. • Other anticipated health benefits derive in part from future prevention of HIV and some STIs acquired through heterosexual sex. Eight percent of annual HIV diagnoses in the United States are among persons with infection attributed to heterosexual contact. STIs are very common, with human papilloma virus (HPV) infection of the anus or genitals occurring in many sexually active persons, although HPV vaccination is highly effective against many serotypes. Current risks for either HIV or other non-HIV STIs may not remain constant in the future and the future risk for any individual neonate, child, or adolescent cannot be definitively defined at the time that a circumcision decision is made. • Considerations for the timing of male circumcision: -Neonatal male circumcision is safer, less expensive, and heals more rapidly than circumcision performed on older boys, adolescent males, and men.
-Most of the health benefits of male circumcision occur after sexual debut (i.e. after becoming sexually active).
-Male circumcision can also be conducted in adulthood when the individual can make the decision for himself. However, male circumcision after sexual debut could result in missed opportunities for: HIV and STI prevention during the window period between sexual debut and circumcision Prevention of UTIs during infancy. • Complications of medically performed male circumcision in the United States are typically uncommon and easily managed. Severe complications are rare in all age groups and occur in 0.23% of all circumcised males overall.
-Among newborns and children aged 1-9 years, most frequently reported complications include bleeding and inflammation of the penis or incomplete wound healing or adhesions requiring corrective procedures.
Complications occur in 0.2% of infants aged ≤ 1 month,25-27 0.4% of infants aged < 1 year,24 and approximately 9% in children aged 1-9 years. -Among persons aged 10 years and older, the most frequently reported complications include those complications reported in younger children as well as wounds of the penis.c Complications occur in approximately 5% of persons in this age group.
-There are not specific data about the frequency of complications in the adolescent age group (13-18 years). • The American Academy of Pediatrics Taskforce on Circumcision states that the health benefits of newborn male circumcision outweigh the risks and that the benefits of newborn male circumcision justify access to this procedure for families who choose it. Page 30, para 1, lines 6-13 states: "In a comprehensive risk-benefit analysis of infant male circumcision based on reviews of the literature and meta-analyses, it is estimated that over a lifetime, benefits exceed risks by a factor of 100:1. Based on a meta-analysis of 22 studies, most of which were conducted in the United States, it is estimated that 32.1% (95% CI = 15.6-49.8) of uncircumcised men compared with 8.8% (95% CI = 4.15-13.2) of circumcised men will experience a UTI in their lifetime, suggesting that lack of circumcision is associated with a 23.3% increased risk of UTI during a man's lifetime."

Document 3: Peer Review Comments and CDC Responses for Information for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV infection, Sexually Transmitted Infections, and other Health Outcomes* and Background, Methods, and Synthesis of Scientific Information Used to Inform "Information for Providers to Share with Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, Sexually Transmitted Infections, and other Health Outcomes"
https://www.cdc.gov/hiv/pdf/risk/MC-HISA-Round-1-Peer-Review-Comments-and-Responses.pdf [6].
This document presents a compilation of all the comments received and the corresponding CDC responses during the first peer review comment period for a

) Information for Providers Counseling Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV infection, Sexually Transmitted Infections, and other Health Outcomes and b) Background, Methods, and Synthesis of Scientific Information Used to Inform "Information for Providers to Share with Male Patients and Parents Regarding Male Circumcision and the Prevention of HIV Infection, Sexually Transmitted Infections, and other Health Outcomes" Document 4:
https://www.cdc.gov/hiv/pdf/risk/MC-HISA-Public-Comments-and-Responses.pdf [7].

Canadian Paediatric Society (CPS) 2015 [8] (Quality level 2-)*
Abstract: The circumcision of newborn males in Canada has become a less frequent practice over the past few decades. This change has been significantly influenced by past recommendations from the Canadian Paediatric Society and the American Academy of Pediatrics, who both affirmed that the procedure was not medically indicated. Recent evidence suggesting the potential benefit of circumcision in preventing urinary tract infection and some sexually transmitted infections, including HIV, has prompted the Canadian Paediatric Society to review the current medical literature in this regard. While there may be a benefit for some boys in high-risk populations and circumstances where the procedure could be considered for disease reduction or treatment, the Canadian Paediatric Society does not recommend the routine circumcision of every newborn male.
*See critiques [9,10] which explain why this position statement was assigned a low quality rating.
British Medical Association 2019 [11] (Quality level 2-) † Non-therapeutic male circumcision (NTMC) of childrena practical guidance for doctors Circumcision of male children including those who are competent, for non-therapeutic reasons, is a controversial area and a wide spectrum of views on circumcision is found within society and within the BMA's membership. For example, there are differing views over whether it is a beneficial, neutral or harmful procedure, and whether it should ever be done on a child who is not capable of deciding for himself or undertaken by non-medical practitioners. A wide spectrum of views can also be found in men who have undergone non-therapeutic male circumcision (NTMC) themselves as childrensome feel aggrieved that they were circumcised before they could decide for themselves, whereas others are pleased if, for example, they believe it is an important part of their identity and/or religion, with many going on to arrange the circumcision of their own children. The BMA has never taken a position in the debate about the acceptability or otherwise of NTMC. Instead, as with other procedures involving children who lack the capacity to consent, we have made clear that those wishing to authorise the procedure for their children need to demonstrate that it is in the child's best interests. Our guidance focuses on providing practical advice for doctors, including the professional standards expected of doctors performing the procedure, good practice guidelines and safeguards, and the type of factors that might be relevant in an assessment of "best interests" in this context. The guidance is not intended to be a comprehensive detailed reflection on all the international and UK debates on the issue. As noted earlier, the guidance is primarily practical, although it also highlights, in brief, some of these debates, to illustrate the diversity of views and the context in which doctors will be making these decisions. Our guidance does not cover circumcision carried out by non-doctors. We note that there is no requirement in law for these practitioners to have proven expertise, although there are standards that some practitioners ascribe to set by external collectives, associations and societies. There have been rare cases in the UK where non-doctor practitioners have been imprisoned due to gross failings in the way the circumcision has been carried out, resulting in the death of, or life-changing injuries to a child. We urge parents who are considering having their child circumcised, to ensure that the practitioner who carries out the circumcision has undergone relevant training and has proven experience and competence in the practice. †See critique published in the Royal College of Paediatrics and Child Health's journal, Paediatrics and Child Health (UK) [12]. [13] (Quality level 2-) Statement from the British Association of Paediatric Surgeons, the Royal College of Nursing, the Royal College of Paediatrics and Child Health, The Royal College of Surgeons of England and the Royal College of Anaesthetists.

Royal College of Surgeons of England 2000
This statement refers to circumcision in male children only. Female circumcision is prohibited by law in the Prohibition of Female Circumcision Act 1995. Circumcision for religious reasons is outside the remit of this statement. Natural history of the foreskin • The foreskin is still in the process of developing at birth and hence is often non-retractable up to the age of three years.
• The process of separation is spontaneous and does not require manipulation.
• By three years of age, 90% of boys will have a retractable foreskin.
• In a small proportion of boys this natural process of separation continues to occur well into childhood. Indications for circumcision • The one absolute indication for circumcision is scarring of the opening of the foreskin making it nonretractable (pathological phimosis). This is unusual before five years of age.
• Recurrent, troublesome episodes of infection beneath the foreskin (balanoposthitis) are an occasional indication for circumcision.